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Spotlight On... Medicaid Personal Care Services

06-07-2011

Are taxpayers footing the bill for improper Medicaid claims for personal care services?

The answer is yes, according to the Office of Inspector General (OIG) of the Department of Health & Human Services. Ongoing and completed OIG work examines Medicaid's payment for these services around the country - the two most recent reports related to audits conducted in North Carolina and Washington State. These audits recommend that the two States refund more than $61.1 million to the Federal Government and call upon the Centers for Medicare & Medicaid Services (CMS) to review an additional $30.3 million in tax dollars that are potentially unallowable.

OIG's review found improper claims:

  • without the required documentation,
  • for services not included in the States' plans of care,
  • for services provided without medical supervision, and
  • for services in which the qualifications for the in-home providers could not be verified.

View the audits on Medicaid payments for personal care services in North Carolina, and for services provided in Washington state. These two audits are part of a larger body of OIG work examining Medicaid personal services. Related work is described and linked below.

What are "Personal Care Services"?

A personal care assistant helping with food preparation for an elderly woman at home

Personal care services are nonmedical services provided to assist with activities of daily living, such as bathing, dressing, light housework, medication management, meal preparation, and transportation. It takes only one accident or illness for anyone to need assistance with these everyday activities.

Already the combined Federal and State bill for personal care services is high and rising. In 2004, the Nation paid $8.25 billion for these services. Just 2 years later, the bill had increased by 20 percent to reach $9.9 billion, and in 2010 it continued to grow, reaching to $13.1 billion.

Related OIG Findings

OIG has reviewed the qualifications of attendants providing personal care services to Medicaid patients and audited Medicaid personal care services claims in New York. The following are highlights of OIG's significant findings, with links to the relevant reports.

Requirements for Personal Care Service Attendants

Improper Claims (OEI-07-08-00430) and Varying State Requirements (OEI-07-05-00250)

  • Across 10 States, Medicaid improperly paid $724 million for personal care services provided by attendants with undocumented qualifications.
  • States establish attendant qualifications, which include safeguards such as criminal background checks, minimum age requirements, or education and training requirements. For 18 percent of claims, attendants' qualifications were undocumented.
  • States have established multiple sets of attendant requirements that often vary among programs and by delivery models within programs, resulting in 301 sets of attendant requirements nationwide. Inconsistencies in requirements and fragmented oversight make it harder for States to ensure that attendant requirements are met.

Improper Payments for Medicaid Personal Care Services

New York City (A-02-07-01054) and New York State (A-02-08-01005)

  • New York City (NYC): OIG estimates that in NYC alone, $275.3 million in Federal funds were improperly claimed by New York in 2004 through 2006 for Medicaid personal care services that did not meet Federal and State requirements.
  • New York State (excluding NYC): More than $100.3 million in Federal tax dollars were claimed improperly by New York State (excluding NYC) from 2004 through 2006 for Medicaid personal care services.
  • In both reviews, Medicaid patients reported to OIG problems with their personal care services providers. The most serious allegations included physical abuse or threats of abuse, property theft, and patient abandonment.

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201